6 frEE DosEs

get your
6 free doses
of advate*
ADVATE is the only recombinant factor VIII (eight) that is FDA approved
for prophylaxis in both adults & children (0-16 years)1
*Free trial program is for new ADVATE patients only. Participants must
receive consultation and approval from their healthcare provider.
Unlocking self-potential
Please see back page for ADVATE Detailed
Important Risk Information. Please see
enclosed ADVATE full Prescribing Information.
www.advate.com | 888.4.ADVATE
enroll in 3 easy steps:
Enroll in the Freedom of Choice free trial program and
get 6 free doses of advate,* along with resources
to help you and your healthcare provider personalize
your treatment.
*Free trial program is for new ADVATE patients only.
Participants must receive consultation and approval
from their healthcare provider.
ONLY WITH ADVATE
• 0 bleeds experienced in 42% of patients during 1 year on prophylaxis
• 98% reduction in median annual bleed rate (ABR) from 44 to 1
with prophylaxis1,a
In a clinical study, after switching from 6 months of on-demand
treatment to 12 months of prophylaxis with ADVATE in 53 previously
treated patients with severe or moderately severe hemophilia A.
• You may be a candidate for Reduced Frequency Dosing
(every third day prophylaxis)
• Physical health-related quality of life improved in patients, mainly
due to clinically meaningful improvements in1,2,a,b:
– the amount of pain experienced by a patient and how much pain
interferes with normal work
– the impact physical health can have on performing work or other
daily activities
b
linically significant changes were not seen in the physical health-related
C
sub-categories of General Health and Physical Functioning and the
mental health-related component score and sub-categories of Mental
Health, Role Emotional, Social Functioning, and Vitality.
Please see back page for ADVATE Detailed Important
Risk Information. Please see enclosed ADVATE full
Prescribing Information.
Complete the enrollment form with your healthcare provider
2
Fax the completed form to 1-800-399-4228
3
Experience life with ADVATE
Indication for ADVATE
1,a
a
1
ADVATE [Antihemophilic Factor (Recombinant), Plasma/Albumin-Free
Method] is a medicine used to replace clotting factor VIII that is missing
in people with hemophilia A (also called “classic” hemophilia). ADVATE is
used to prevent and control bleeding in adults and children (0-16 years)
with hemophilia A. Your healthcare provider may give you ADVATE when
you have surgery. ADVATE can reduce the number of bleeding episodes
in adults and children (0-16 years) when used regularly (prophylaxis).
ADVATE is not used to treat von Willebrand Disease.
Selected Important Risk Information for ADVATE
• You should not use ADVATE if you are allergic to mice or hamsters or
any ingredients in ADVATE.
• You may have to have blood tests done after getting ADVATE to be sure
that your blood level of factor VIII is high enough to clot your blood.
• Side effects that have been reported with ADVATE include: cough, sore
throat, unusual taste, abdominal pain, diarrhea, nausea/vomiting, headache,
fever, dizziness, hot flashes, chills, sweating, joint swelling/aching, itching,
hematoma, swelling of legs, runny nose/congestion, and rash.
Trial Program Enrollment Form
FAX COMPLETED FORM TO: 1-800-399-4228
Instructions for Physician
1.In the “Freedom of Choice” trial program, patients are eligible for six (6) doses of ADVATE [Antihemophilic Factor (Recombinant),
Plasma/Albumin-Free Method].
2.This prescription will be filled and shipped via overnight courier directly to the patient’s address of choice. (No PO boxes, please.)
3.Complete this enrollment form with patient and provider information.
4.Sign the authorization and release below.
5.Fax completed form to: 1-800-399-4228.
·· Please see the prescribing information enclosed in the “Freedom of Choice” trial program materials.
·· These samples cannot be exported or transferred in exchange for money, other property, or services. No portion of these samples can be used
for reimbursement purposes from Medicare, Medicaid, or any other third-party program, which provides cost- or charge-based reimbursement
to the participating institution, either directly or indirectly.
·· The trial offer prescription is valid for patients not currently using ADVATE. This offer is valid one time only for each patient, with no refills.
The patient must obtain a refill prescription for ADVATE for future use.
Patient Information
Patient:DOB:
FIRSTLAST
MM/DD/ YYYY
Parent/Guardian (when applicable):
FIRSTLAST
Address (where product can be received; no PO boxes):
City:
State: Primary phone number:
Alternate phone number:
Allergies:
None
Aspirin
Codeine
Sulfa
Other:Gender:
ZIP:
Male
Female
Select for Spanish-speaking patient
Diagnosis:
Prescriber Information
Physician name:
Facility name:
License # (required by law):
Tax ID #:
Address:
Phone:
Prescription Information
Patient weight:
kg
Baseline activity:
lb
%Target activity level desired:
%
Total ADVATE IUs required for one dose:
(ADVATE vial potency will be determined by the fulfilling pharmacy. Patient will receive enough vials to equal six [6] doses.)
Special dosing instructions:
Authorized refills=0. The prescription is valid for one time only with no refills. The patient must obtain a refill prescription for ADVATE for future use.
Physician/Prescriber Authorization and Release
I hereby authorize the agents of Baxter Healthcare Corporation to use the above information to process ADVATE samples provided free of charge
to my patient. I have obtained consent from this patient to release this information to the mail order pharmacy and the program call center (the
agents). I understand that the agents of Baxter Healthcare Corporation will keep this information confidential and will use it only for the
“Freedom of Choice” trial program for ADVATE. This usage might include a follow-up survey about the patient’s experience and my experience
with “Freedom of Choice.” These samples will not be exported or transferred in exchange for money, other property, or services.
No portion of these samples will be used for reimbursement purposes from Medicare, Medicaid, or any other third-party program, which
provides cost- or charge-based reimbursement to the participating institution, either directly or indirectly.
Physician/Prescriber Signature:
Date:
Baxter and Advate are registered trademarks of Baxter International Inc. ©Copyright (December 2012), Baxter Healthcare Corporation. All rights reserved. Printed in the U.S.A. HYL8213-1
Detailed Important Risk Information for ADVATE
You should not use ADVATE if you are allergic to mice or hamsters or any
ingredients in ADVATE.
You should tell your healthcare provider if you have or have had any medical
problems, take any medicines, including prescription and non-prescription
medicines and dietary supplements, have any allergies, including allergies to
mice or hamsters, are nursing, are pregnant, or have been told that you have
inhibitors to factor VIII.
You can have an allergic reaction to ADVATE. Call your healthcare provider
right away and stop treatment if you get a rash or hives, itching, tightness
of the throat, chest pain or tightness, difficulty breathing, lightheadedness,
dizziness, nausea, or fainting.
Your body may form inhibitors to factor VIII. An inhibitor is part of the body’s
normal defense system. If you form inhibitors, it may stop ADVATE from
working properly. Consult with your healthcare provider to make sure you
are carefully monitored with blood tests for the development of inhibitors
to factor VIII.
6 free doses
of advate*
*Free trial program is for new ADVATE patients
only. Participants must receive consultation and
approval from their healthcare provider.
Side effects that have been reported with ADVATE include: cough, sore throat,
unusual taste, abdominal pain, diarrhea, nausea/vomiting, headache, fever,
dizziness, hot flashes, chills, sweating, joint swelling/aching, itching, hematoma,
swelling of legs, runny nose/congestion, and rash.
Call your healthcare provider right away about any side effects that bother
you or if your bleeding does not stop after taking ADVATE.
Please see enclosed ADVATE full Prescribing Information.
References
1. ADVATE Prescribing Information. Westlake Village, CA: Baxter Healthcare Corporation;
July 2012. 2. Maruish ME, ed. User’s Manual for the SF-36v2 Health Survey. 3rd ed.
Lincoln, RI: QualityMetric Incorporated; 2011.
Baxter and Advate are registered trademarks of Baxter International Inc.
©Copyright (December 2012), Baxter Healthcare Corporation.
All rights reserved. HYL8213-1
www.advate.com | 888.4.ADVATE